Wednesday, 8 April 2015

Norwegian Department of Health positive to harm reducing e-cigarettes

The Norwegian Department of Health recently published and presented their Public Health Report to the Parliament. According to the Norwegian governments' official web-portal, regjeringen.no, this report presents new policies in areas that the government believes has not
been sufficiently prioritized or that require new approaches.

As I've mentioned earlier, The Norwegian Institute for Alcohol and Drug Research (SIRUS), wrote an answer to a request for input by the Department of Health during the process of writing this report. SIRUS' answer focused on harm reduction. After this Public Health Report was published SIRUS' head of research, Karl Erik Lund, was positively surprised by the impact their input:

We
prepared a note on the need for harm reduction in the tobacco area but had
little hope that the Department of Health would anchor harm reduction ideology in the Public
Health Report. Now, however, the Norwegian health authorities for the first time has
given the topic discussion in an official, authoritative publication and
additionally they've taken a quite positive stance.

I've translated what the report says about harm reduction in the tobacco area:

Harm reduction in the tobacco area

The emergence of electronic cigarettes has intensified the debate about whether harm reduction should be a supplement to the traditional tobacco politics. Smokers who do not manage to quit will be able reduce their health risks by switching to e-cigarettes, even if these are not necessarily completely harmless.

Harm reduction as a political strategy has until now had no place in the Norwegian tobacco policy. The government is open to a rethinking of this area when it comes to e-cigarettes, but have not yet concluded on how the products should be regulated.Traditionally the authorities' policy to reduce tobacco use have had it's roots in three principles of medical ethics: The no-harm principle discourages the use of products which cause harm due to toxic content. The precautionary principle warns against use of products where it can not be excluded that undiscovered harmful consequences may occur in the future, and that these may be irreversible. The loss ofautonomyprinciple warns against use of products which can be addictive.

A comparative perspective implies that the adverse effects of cigarette smoking are used as basis for comparison when evaluating the adverse effects of the use of e-cigarettes.Conventional cigarettes and e-cigarettes are nicotine products in a so-called substitutional relationship, which means that their user functions and users are strongly overlapping. There are still no epidemiological studies of any consequential damage by prolonged use of e-cigarettes. However, a number of studies indicate that the transition from tobacco cigarettes to e-cigarettes will result in a significant risk reduction for the individual smoker. Expert groups have estimated that the overall health risks of using e-cigarettes probably constitute less than 10 percent of the overall risk of cigarette smoking.

Although
the transition from tobacco cigarettes to e-cigarettes will be harm
reducing for the individual smoker, their effectiveness on community
level will depend on the extent to which e-cigarettes may come to
recruit non-smokers, postponing quitting, lead to double-use and recruit youth smoking.

Based
on current knowledge there is no basis for assuming that e-cigarettes
will cause adverse effects on a large-scale population. Users
of e-cigarettes is currently almost exclusively smokers or former
smokers, and e-cigarettes are used to reduce tobacco consumption, to stop
smoking or to prevent relapse to smoking. According to the Institute of Public Health smoking is the single most important cause of differences in life
expectancy between people with high and low socio-economic status. The Norwegian Institute for Alcohol and Drug Research has estimated that about 200,000 of the 700,000 daily smokers in this country have characteristics associated with low probability of smoking cessation. The large difference in risk between tobacco and e-cigarettes suggests
that access to e-cigarettes will improve the health of the vast
majority of users - which is the smokers.There are currently many disreputable manufacturers of e-cigarettes and studies have shown that the content of the products often do not match the content declaration. It
is therefore a prerequisite for an eventual repeal of the current
prohibition that quality requirements for the products are set, that the sales are regulated and that e-cigarettes in no way will be marketed to young
people.

As you've probably noticed there are some points here that are still not concluded on, regulation being the most important one. They do not say much about how much or what kinds of regulation they envision. However, the fact that they seem to have understood the enormous value and efficiency of a harm reduction strategy is a huge step in the right direction.

So, while politicians in a lot of other places seem to work for strict regulations or even bans on e-cigarettes, seemingly unable to grasp the concepts of harm reduction, it looks like we're moving in the other direction here in Norway, where we already have a ban (on nicotine e-liquid that is). This is quite remarkable actually, as we have a strong tradition for over-usage of the precautionary principle here. As I've mentioned before, we even had a total ban on skateboarding from 1978 to 1989 here. So what is the reason that our politicians and health officials seems to have a relatively positive attitude towards the harm reducing e-cigarettes now? Well, we are indeed lucky to have SIRUS on "our side" here in Norway, but a lot of hard work and fighting is also done by the vapers themselves and we must not forget the tireless efforts made by members and the leadership of the Norwegian Union of Vapers (NDS). Here is what Karl Erik Lund wrote in the NDS Facebook group after the report was published:

This mustbe interpreted asa more sympatheticattitude to harmreductionin general ande-cigarettes in particular.Ournotehas been important, but it's stillallinquiriesandactivityfrom youvaperswhichhave preparedthe groundforthis shiftin views one-cigarettes among the political leadership.

Personally I also believe that the way e-cigarettes have been presented in the media lately have contributed a lot to this. We've seen vapers telling their stories about how the e-cigarettes have affected their lives, stories about how Norwegians travel across the border to Sweden to buy e-cigarettes and liquid, and Karl Erik Lund and SIRUS have done some extremely important work here by quickly debunking the horror stories that hit the media.

The Norwegian Department of Health recently published and presented their Public Health Report to the Parliament. According to the Norwegian governments' official web-portal, regjeringen.no, this report presents new policies in areas that the government believes has not
been sufficiently prioritized or that require new approaches.

As I've mentioned earlier, The Norwegian Institute for Alcohol and Drug Research (SIRUS), wrote an answer to a request for input by the Department of Health during the process of writing this report. SIRUS' answer focused on harm reduction. After this Public Health Report was published SIRUS' head of research, Karl Erik Lund, was positively surprised by the impact their input:

We
prepared a note on the need for harm reduction in the tobacco area but had
little hope that the Department of Health would anchor harm reduction ideology in the Public
Health Report. Now, however, the Norwegian health authorities for the first time has
given the topic discussion in an official, authoritative publication and
additionally they've taken a quite positive stance.

I've translated what the report says about harm reduction in the tobacco area:

Harm reduction in the tobacco area

The emergence of electronic cigarettes has intensified the debate about whether harm reduction should be a supplement to the traditional tobacco politics. Smokers who do not manage to quit will be able reduce their health risks by switching to e-cigarettes, even if these are not necessarily completely harmless.

Harm reduction as a political strategy has until now had no place in the Norwegian tobacco policy. The government is open to a rethinking of this area when it comes to e-cigarettes, but have not yet concluded on how the products should be regulated.Traditionally the authorities' policy to reduce tobacco use have had it's roots in three principles of medical ethics: The no-harm principle discourages the use of products which cause harm due to toxic content. The precautionary principle warns against use of products where it can not be excluded that undiscovered harmful consequences may occur in the future, and that these may be irreversible. The loss ofautonomyprinciple warns against use of products which can be addictive.

A comparative perspective implies that the adverse effects of cigarette smoking are used as basis for comparison when evaluating the adverse effects of the use of e-cigarettes.Conventional cigarettes and e-cigarettes are nicotine products in a so-called substitutional relationship, which means that their user functions and users are strongly overlapping. There are still no epidemiological studies of any consequential damage by prolonged use of e-cigarettes. However, a number of studies indicate that the transition from tobacco cigarettes to e-cigarettes will result in a significant risk reduction for the individual smoker. Expert groups have estimated that the overall health risks of using e-cigarettes probably constitute less than 10 percent of the overall risk of cigarette smoking.

Although
the transition from tobacco cigarettes to e-cigarettes will be harm
reducing for the individual smoker, their effectiveness on community
level will depend on the extent to which e-cigarettes may come to
recruit non-smokers, postponing quitting, lead to double-use and recruit youth smoking.

Based
on current knowledge there is no basis for assuming that e-cigarettes
will cause adverse effects on a large-scale population. Users
of e-cigarettes is currently almost exclusively smokers or former
smokers, and e-cigarettes are used to reduce tobacco consumption, to stop
smoking or to prevent relapse to smoking. According to the Institute of Public Health smoking is the single most important cause of differences in life
expectancy between people with high and low socio-economic status. The Norwegian Institute for Alcohol and Drug Research has estimated that about 200,000 of the 700,000 daily smokers in this country have characteristics associated with low probability of smoking cessation. The large difference in risk between tobacco and e-cigarettes suggests
that access to e-cigarettes will improve the health of the vast
majority of users - which is the smokers.There are currently many disreputable manufacturers of e-cigarettes and studies have shown that the content of the products often do not match the content declaration. It
is therefore a prerequisite for an eventual repeal of the current
prohibition that quality requirements for the products are set, that the sales are regulated and that e-cigarettes in no way will be marketed to young
people.

As you've probably noticed there are some points here that are still not concluded on, regulation being the most important one. They do not say much about how much or what kinds of regulation they envision. However, the fact that they seem to have understood the enormous value and efficiency of a harm reduction strategy is a huge step in the right direction.

So, while politicians in a lot of other places seem to work for strict regulations or even bans on e-cigarettes, seemingly unable to grasp the concepts of harm reduction, it looks like we're moving in the other direction here in Norway, where we already have a ban (on nicotine e-liquid that is). This is quite remarkable actually, as we have a strong tradition for over-usage of the precautionary principle here. As I've mentioned before, we even had a total ban on skateboarding from 1978 to 1989 here. So what is the reason that our politicians and health officials seems to have a relatively positive attitude towards the harm reducing e-cigarettes now? Well, we are indeed lucky to have SIRUS on "our side" here in Norway, but a lot of hard work and fighting is also done by the vapers themselves and we must not forget the tireless efforts made by members and the leadership of the Norwegian Union of Vapers (NDS). Here is what Karl Erik Lund wrote in the NDS Facebook group after the report was published:

This mustbe interpreted asa more sympatheticattitude to harmreductionin general ande-cigarettes in particular.Ournotehas been important, but it's stillallinquiriesandactivityfrom youvaperswhichhave preparedthe groundforthis shiftin views one-cigarettes among the political leadership.

Personally I also believe that the way e-cigarettes have been presented in the media lately have contributed a lot to this. We've seen vapers telling their stories about how the e-cigarettes have affected their lives, stories about how Norwegians travel across the border to Sweden to buy e-cigarettes and liquid, and Karl Erik Lund and SIRUS have done some extremely important work here by quickly debunking the horror stories that hit the media.